|Hemoperitoneum in a cirrhotic patient due to rupture of retroperitoneal varix.|
|Jump to Full Text|
|PMID: 19404409 Owner: NLM Status: MEDLINE|
|The rupture of retroperitoneal varices is a rare and catastrophic complication of portal hypertension. We describe a case of this nature, the first in Brazilian medical literature, and also reviewing all previous 34 cases. We systematically analyzed all therapeutic approach and propose a management algorithm for diagnosis and treatment of this lethal condition. The majority of the patients presented with abdominal pain, distention and hypotension, and developed hemorrhagic shock. Rupture of retroperitoneal varices can be properly managed if an early diagnosis is made and surgery is performed promptly, which is the only effective treatment. Arteriography should be used when the suspicion is of rupture of hepatocellular carcinoma.|
|Igor Rafael Sincos; Grace Mulatti; Sheila Mulatti; Ilana Cristina Sincos; Sergio Q Belczak; Valdir Zamboni|
Related Documents :
|15483549 - Spontaneous rupture of the popliteus tendon in a 74-year-old woman and review of the li...
16596539 - Early rupture of subclavian vein catheter: a case report and literature review.
8336159 - Cerebral amyloid angiopathy: a significant cause of cerebellar as well as lobar cerebra...
11815839 - Spontaneous dissection of the superior mesenteric artery.
15300739 - Prenatal rupture of a left ventricular diverticulum: a case report and review of the li...
18810389 - Out of the ring and into a sling: acute latissimus dorsi avulsion in a professional wre...
8010539 - Serum tryptase in idiopathic anaphylaxis: a case report and review of the literature.
19517029 - Use of intravitreal triamcinolone in the treatment of macular edema related to retinal ...
19061169 - Pediatric intervertebral disc calcification.
|Type: Case Reports; Journal Article Date: 2009-04-23|
|Title: HPB surgery : a world journal of hepatic, pancreatic and biliary surgery Volume: 2009 ISSN: 1607-8462 ISO Abbreviation: HPB Surg Publication Date: 2009|
|Created Date: 2009-04-30 Completed Date: 2009-07-24 Revised Date: 2013-06-02|
Medline Journal Info:
|Nlm Unique ID: 9002972 Medline TA: HPB Surg Country: United States|
|Languages: eng Pagination: 240780 Citation Subset: IM|
|Department of General Surgery of Universitary Hospital and Clinics Hospital, University of São Paulo Medical School (FMUSP), 05403-000 São Paulo, SP, Brazil. firstname.lastname@example.org|
|APA/MLA Format Download EndNote Download BibTex|
Emergency Service, Hospital
Emergency Treatment / methods
Hemoperitoneum / diagnosis, etiology*, surgery
Hemostasis, Surgical / methods*
Hypertension, Portal / complications, diagnosis*
Laparotomy / methods
Ligation / methods
Liver Cirrhosis / complications*, diagnosis
Multiple Organ Failure / diagnosis
Postoperative Complications / physiopathology
Retroperitoneal Space / blood supply
Rupture, Spontaneous / etiology, surgery
Severity of Illness Index
Varicose Veins / complications, diagnosis, surgery*
Journal ID (nlm-ta): HPB Surg
Journal ID (publisher-id): HPB
Publisher: Hindawi Publishing Corporation
Copyright ? 2009 Igor Rafael Sincos et al.
open-access: This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Day: 7 Month: 5 Year: 2008
Revision Received Day: 7 Month: 10 Year: 2008
Accepted Day: 3 Month: 2 Year: 2009
Print publication date: Year: 2009
Electronic publication date: Day: 23 Month: 4 Year: 2009
Volume: 2009E-location ID: 240780
PubMed Id: 19404409
|Hemoperitoneum in a Cirrhotic Patient Due to Rupture of Retroperitoneal Varix|
|Igor Rafael Sincos1, 2I2*|
|Ilana Cristina Sincos1|
|Sergio Q. Belczak1|
1Department of General Surgery of Universitary Hospital and Clinics Hospital, University of S?o Paulo Medical School (FMUSP), 05403-000 S?o Paulo, SP, Brazil
2Section of Vascular Surgery, Clinics Hospital, University of S?o Paulo Medical School (FMUSP), Avienda Dr. En?as de Carvalho Aguiar 255, 05403-000 S?o Paulo, SP, Brazil
|Correspondence: *Igor Rafael Sincos: email@example.com
[other] Recommended by Richard Charnley
The first case of rupture of retroperitoneal varices, a rare and catastrophic complication of portal hypertension, has been reported in 1958 . According to our research over Medline and PubMed, to date, only 34 similar cases have been described with high mortality rates even nowadays [1?38]. We used hemoperitoneum and varices as keywords for search. The aim of this article is to describe a case of this nature, the first in Brazilian medical literature, and also reviewing all previous cases. We systematically analyzed all therapeutic approaches and propose a management algorithm for diagnosis and treatment of this lethal condition. Rupture of retroperitoneal varices can be properly managed if an early diagnosis is made and surgery is performed promptly.
A 51-year-old woman entered the Emergency Department of Universitary Hospital of the University of Sao Paulo (USP) in March 2006 presenting with abdominal pain for two days, associated with nausea and vomits. She also reported abdominal distention for the last fourteen days.
Her past medical history showed a chronic abuse of alcohol leading to liver cirrhosis associated to Hepatitis B. She had been under medical follow-up with a clinician from 2001 to 2004, when she abandoned medical care.
Her physical examination was remarkable for an ill-appearing, pale, jaundiced, and dyspneic patient. She had a heart rate of 100 beats/min and a systolic blood pressure of 95 and diastolic of 65 mm Hg. Abdominal examination revealed diminished bowel sounds, a slight distention, and diffuse tenderness during palpation, with no guarding. Admission laboratory values showed hemoglobin level of 6.4 g/dL. MELD score of 24, Child-Pugh grade C.
An endoscopy was carried out, which showed a healed distal esophageal ulcer, a hiatal hernia, and erosive gastritis of the body and antrum. There were no signs of esophageal varices.
A few hours after entering the Emergency Department she developed severe hypotension of 70/40 mm Hg, Glasgow coma scale 14, tachycardia of 125 beats/min. She underwent volume resuscitation with no sustained response. Treatment for Spontaneous Bacterial Peritonitis was initiated with Ceftriaxone. Additional treatment with norepinephrine was started as she remained hypotensive even after the continuous infusion of volume. She was then transferred to the intensive care unit. She had progressive hemodynamic instability, abdominal distention, and altered mental status, requiring endotracheal intubation.
At this time a surgeon was requested to examine the patient. A paracentesis was carried out; the peritoneal fluid was hemorrhagic with a hematocrit of 12%. Laboratory values at this moment were hemoglobin level of 3.8 and INR of 7.29. She was then transfused with packed RBCs and plasma. Reaching hemodynamic stability she underwent an exploratory laparotomy.
About 5 L of blood were evacuated from the peritoneal cavity. A ruptured retroperitoneal varix was found to be the cause of bleeding, next to the mesenteric root. Direct ligation of the vessel led the bleeding to stop (Figure 1). The liver was cirrhotic; an exuberant collateral circulation was seen on the retroperitoneum and on the abdominal wall, with canalization of the Umbilical vein, with an 8 mm diameter. The Retzius vein was identified in both paracolic gutters, with a lot of collaterals. A liver biopsy was made. Later histopathological evaluation revealed steatohepatitis grade IV (alcoholic and nonalcoholic).
Returning to the intensive care unit the patient was massively transfused with packed RBCs and plasma for anemia and coagulopathy. She continued to be hemodynamically unstable associated with renal and hepatic failure. On the sixth posoperatory she died of multiple organ dysfunction syndrome.
Trauma and nonmalignant gynecological conditions account for more than 90% of intraperitoneal hemorrhages . The main cause of hemoperitoneum in women is the rupture of an ectopic pregnancy; in men, the major cause is the posttraumatic rupture of the liver or spleen . The vascular causes are also relevant, as the Aorta Aneurysm, rupture of viscera, and hemorrhagic pancreatitis. Inflammatory and hematological disorders rarely manifest as hemoperitoneum.
In cirrhotic patients with ascites the intraperitoneal bleeding occurs most of the times due to structural lesions such as hepatocellular carcinoma or ovary cancer and rupture of intraperitoneal varices .
The intraperitoneal varices rupture is a rare event, whose incidence unknown, and it is related to severe portal hypertension. We believe that the real incidence of this pathology is much superior than the 34 cases described in literature due to misdiagnosis. It also appears in patients with terminal liver disease, mostly in a fulminate way.
Portal hypertension leads to the development of portosystemic shunts in well-defined anatomic sites. The most acknowledged sites include the gastroesophageal veins connecting the azigohemiazigos system, the hemorrhoidary veins from the inferior mesenteric vein, communicating with the tributaries of the Internal Iliac Vein and the Umbilical and periumbilical veins draining to the left Portal Vein and to the epigastric veins of the anterior abdominal wall. The recanalization of the Umbilical vein is known as Cruveillier-Baumgarten Syndrome [1, 4]. There are also shunts of the Retzius veins connecting the Colic veins with the lumbar and the lower intercostals veins; pancreatic veins connecting the splenic vein and the left renal vein; numerous venous canals communicating the liver with the diaphragm (Sappey veins) .
There are 34 cases of intraperitoneal bleeding due to rupture of varices described in literature, as shown in Table 1. Including our patient, 27 were men and 8 were women. The age onset was 21 to 76 years old (average of 48.8). Only one case reported in literature was of a noncirrhotic patient. Table 1 summarizes the presentation, diagnosis, treatment, and results of the cases described in literature.
The majority of the patients presented with abdominal pain, distention and hypotension, and developed hemorrhagic shock. The diagnosis was established by paracentesis, angiography, ultrasound Doppler, and tomography. Even so, the diagnosis was confirmed only by laparotomy.
The hemoperitoneum diagnosis is confirmed by paracentesis when the Ht > 5%. The paracentesis was important in the diagnosis and surgical indication is most of the cases. Only two cases out of ten who survived did not undergo the paracentesis [5, 6]. In one of them, the diagnosis was suggested via tomography and confirmed at laparotomy .
The angiography was used as an attempt to achieve the diagnosis in 6 cases of hemoperitoneum by varices inside the abdomen [7?12]. The source of the bleeding was identified only in one patient. However, this patient past away probably because of recurrent bleeding . In one case the angiogram may have anticipated the recurrent bleeding and finally his death .
The only effective treatment was surgery. None of the 7 patients treated in a nonchirurgical basis survived. Twenty eight were operated, twelve survived. The global mortality rate was 65.7%. And for the patients submitted to surgery it was of 57.1%. The causes leading of death were uncontrollable or recurrent bleeding, liver failure, kidney failure, heart failure, and aspiration of blood from ruptured esophageal varices.
Out of 28 cases that underwent surgery, in twenty six the ligation of the bleeding vessels was successful, and eleven survived the after surgery period. In two cases who underwent surgery, the ligation was not possible [12, 13], and the patient died of bleeding, even after the use of a portocaval shunt as an attemptive to relieve the portal hypertension . Only one patient survived after a porto-systemic shunt .
The management of the bleeding from intra-abdominal varices is difficult since there are no randomized trials due to the rareness of this situation . However, this condition seems to be underestimated, probably because most of the patients present tense ascitis and hepatic disease in a terminal state leading rapidly to death .
The patients' survival rate seems to be related to three important facts: the patient's functional hepatic reserve, the importance of the hemorrhagic shock in its presentation, and the early operative intervention and control of the bleeding source [3, 16].
The first challenge in the management of these cases is in the differential diagnosis of acute hemorrhagic abdomen in a cirrhotic patient. We suggest a flowchart based on the analysis of all the published cases related to intraperitoneal varices and a review of the articles related to the other causes of hemoperitoneum in cirrhotic patients (Figure 2).
The paracentesis with Ht over 5% is a precise indicator of intra-abdominal bleeding that can dimish the risk of unnecessary laparotomies . It may be repeated in another site to exclude a punction accident and has rarely been to relate to hemorrhagic complications .
Once the bleeding in a cirrhotic patient was identified, the diagnostic orientation is made on differing HCC rupture, bleeding intra-abdominal varices, vascular causes such as aorta's aneurism, and gynecological causes.
We suggest checking the dosage level of HCG in women, followed by Abdominal Duplex Scan in both sexes as the first diagnostic step. Duplex scan can provide information on the Aorta and its branches, the abdominal collateral circulation, the patency of the Portal Vein, hepatic nodules and tumors, and the ovaries.
Computerized tomographic scanning was suggested by Bataille et al.  and Goldstein et al.  as the first diagnostic approach for excluding rupture of hepatocellular carcinoma and all other causes. It is, though, more expensive than the Duplex Scan, and it is not always available in all emergency services. On the other hand, it provides more detailed information on other acute hemorrhagic abdomen.
Arteriography has proved to be an inefficient investigation for diagnosis and treatment of retroperitoneal bleeding varices. It postpones the surgical treatment , the only one that has been effective in these cases. Thus, it is very important to notice that arteriography has a fundamental role in the treatment of the rupture of hepatocellular carcinoma, which is the main differential diagnosis as mentioned before.
The fundamental treatment of variceal bleeding is the ligation of the vessel. Nevertheless, the Surgical Portosystemic Shunt or the Transjugular Intrahepatic Portosystemic Shunt (TIPSS) must be considered for selected patients.
In the operation room, the decision of performing a Portosystemic shunt must take into consideration the patient's clinical condition and the time needed to perform the shunt. In unstable patients and with little hepatic functional reserve we strongly suggest not increasing the surgical time. However, multiple bleeding varices or the possibility of a new bleed should be analyzed in order to decide if the shunt must be performed.
TIPSS was not performed in any of the reported cases. Nevertheless, the way we understand its use for treatment of gastroesophageal varices can help us in treating variceal bleeding from the retroperitoneum. Therefore TIPSS can be used mainly for the patient's postoperatory when there is suspicion of a new bleeding, or for diminishing the portal tension in selected patients serving as a bridge for liver transplantation. Before deciding if the TIPSS will be performed, one must be aware of its contraindications and complications as bleeding, perforation of the liver capsule, and encephalopathy, among others.
Bleeding intraperitoneal varix is a rare complication of portal hypertension, but carries a high mortality rate. Nonetheless, the physician must know this condition, as the clinical suspicion is the only way of establishing an early diagnosis and indicating surgery at once, which is the only effective treatment.
We suggest a flowchart to optimize the treatment of the acute hemorrhagic abdomen in the cirrhotic patient. Paracentesis followed by ultrassonography with Duplex Scan or Computerized Tomography seems to be the most important procedure for establishing the correct diagnosis of abdominal pain, distention, and shock. Thereafter, surgery must be performed as soon as possible in case of ruptured varices. Arteriography should be used when the suspicion is of rupture of hepatocellular carcinoma.
|1.||Elis H,Griffiths PWW,MacIntyre A. H?moperitoneum. A record of 129 consecutive patients with notes on some unusual casesBritish Journal of Surgery 1958;45(194):606–610. [pmid: 13560763]|
|2.||Akriviadis EA. Hemoperitoneum in patients with ascitesAmerican Journal of Gastroenterology 1997;92(4):567–575. [pmid: 9128301]|
|3.||Fox L,Crane SA,Bidari C,Jones A. Intra-abdominal hemorrhage from ruptured varicesArchives of Surgery 1982;117(7):953–956. [pmid: 7092547]|
|4.||Armstrong EL,Adams WL,Tragerman LJ,Townsend EW. The Cruveilhier-Baumgarten syndrome. Review of literature and report of two additional casesAnnals of Internal Medicine 1942;16:113–151.|
|5.||Goldstein AM,Gorlick N,Gibbs D,Fern?ndez-del Castillo C. Hemoperitoneum due to spontaneous rupture of the umbilical veinAmerican Journal of Gastroenterology 1995;90(2):315–317. [pmid: 7847310]|
|6.||Ross AP. Portal hypertension presenting with haemoperitoneumBritish Medical Journal 1970;1(5695):p. 544.|
|7.||L?aut? F,Frampas E,Mathon G,Leborgne J,Dupas B. H?mop?ritoine massif par rupture d'une varice intra-abdominaleJournal de Radiologie 2002;83(11):1775–1777. [pmid: 12469017]|
|8.||Sprayregen S,Brandt LJ,Bohm S,Stechel R. Bleeding intraperitoneal varix. Demonstration by arteriography and successful treatment with infusion of vasopressin into the superior mesenteric arteryAngiology 1978;29(11):857–861. [pmid: 727566]|
|9.||Shapero TF,Bourne RH,Goodall RG. Intra abdominal bleeding from variceal vessels in cirrhosisGastroenterology 1978;74(1):128–129. [pmid: 618421]|
|10.||Lyon DT,Mantia AG,Schubert TT. Hemoperitoneum from a ruptured varix in cirrhosis. Case report and literature reviewAmerican Journal of Gastroenterology 1979;71(6):611–616. [pmid: 453161]|
|11.||Fawaz KA,Kellum JM,Deterling RA. Intraabdominal variceal bleedingAmerican Journal of Gastroenterology 1982;77(8):578–579. [pmid: 7102642]|
|12.||Miller J,Dinnen J. Ruptured abdominal varixThe New England Journal of Medicine 1968;278(9):p. 508.|
|13.||Mall K,Grundies H. Haemoperitoneum als Folge portaler hypertensionMedizinische Klinik 1974;69:2075–2076. [pmid: 4444671]|
|14.||Tarbe De Saint-Hardouin C,Peigney N,Hannoun L,et al. H?mo?ritoine par rupture de laveine ombilicaleGastroent?rologie Clinique et Biologique 1988;12:501–502.|
|15.||Bataille L,Baillieux J,Remy P,Gustin R-M,Deni? C. Spontaneous rupture of omental varices: an uncommon cause of hypovolemic shock in cirrhosisActa Gastro-Enterologica Belgica 2004;67(4):351–354. [pmid: 15727080]|
|16.||Puche P,Jacquet E,Jaber S,et al. Spontaneous haemoperitoneum due to a ruptured intra-abdominal varix with cirrhosisAnnales de Chirurgie 2007;144(2):157–159.|
|17.||Smalley SR,Moertel CG,Hilton JF,et al. Hepatoma in the noncirrhotic liverCancer 1988;62(7):1414–1424. [pmid: 2843280]|
|18.||Luna G,Florence L,Johansen K. Hepatocellular carcinoma. A 5 year institutional experienceAmerican Journal of Surgery 1985;149(5):591–594. [pmid: 2986472]|
|19.||Kew MC,Hodkinson J. Rupture of hepatocellular carcinoma as a result of blunt abdominal traumaAmerican Journal of Gastroenterology 1991;86(8):1083–1085. [pmid: 1650131]|
|20.||Chen M-F,Hwang T-L,Jeng L-B,Jan Y-Y,Wang C-S. Surgical treatment for spontaneous rupture of hepatocellular carcinomaSurgery Gynecology and Obstetrics 1988;167(2):99–102.|
|21.||Okazaki M,Higashihara H,Koganemaru F,et al. Intraperitoneal hemorrhage from hepatocellular carcinoma: emergency chemoembolization or embolizationRadiology 1991;180(3):647–651. [pmid: 1651524]|
|22.||Nelson BE,Carcangiu ML,Chambers JT. Intraabdominal hemorrhage with pulmonary large cell carcinoma metastatic to the ovaryGynecologic Oncology 1992;47(3):377–381. [pmid: 1335432]|
|23.||Kosowsky JM,Gibler WB. Massive hemoperitoneum due to rupture of a retroperitoneal varixJournal of Emergency Medicine 2000;19(4):347–349. [pmid: 11074328]|
|24.||Ben-Ari Z,McCormick AP,Jain S,Burroughs AK. Spontaneous haemoperitoneum caused by ruptured varices in a patient with non-cirrhotic portal hypertensionEuropean Journal of Gastroenterology and Hepatology 1995;7(1):87–90. [pmid: 7866819]|
|25.||Gross W,Kaffarnik H,Strik WO. Intraperitoneal hemorrhage due to liver cirrhosisMunchener Medizinische Wochenschrift 1963;105:529–530. [pmid: 13950798]|
|26.||Steiner H. Acute hemoperitoneum. Report on 140 cases of intra-abdominal massive hemorrhageSchweizerische Medizinische Wochenschrift 1966;96(27):875–882. [pmid: 5989002]|
|27.||Rothschild JJ,Gelernt I,Sloan W. Ruptured mesenteric varix in cirrhosis?unusual cause for hemoperitoneumThe New England Journal of Medicine 1968;278(2):97–98. [pmid: 5634486]|
|28.||Philippe JM,Dusehu E,Fi?vet P. Rupture of the varices of the colo-parietal ligament. Possible cause of hemoperitoneum in the cirrhotic patientLa Nouvelle Presse Medicale 1977;6(8):p. 659.|
|29.||Legue E,de Calan L,Ozoux JP,Brizon J. Rupture of varices of the round ligament. Unusual cause of spontaneous hemoperitoneum in the cirrhotic patientPresse Medicale 1983;12(47):p. 3004.|
|30.||Jhung JW,Micolonghi TS. Ruptured mesenteric varices in hepatic cirrhosis: a rare cause of intraperitoneal hemorrhageSurgery 1985;97(3):377–380. [pmid: 3975859]|
|31.||Ragupathi K,Bloom A,Pai N. Hemoperitoneum from ruptured omental varicesJournal of Clinical Gastroenterology 1985;7(6):537–538. [pmid: 4086751]|
|32.||Paizis B,Krespis E,Filiotou A,Kalochairetis P,Golematis B. Rupture of a periumbilical vein causing hemoperitoneum in a cirrhotic patientThe Mount Sinai Journal of Medicine 1986;53(2):123–125.|
|33.||Sato H,Kamibayashi S,Tatsumura T,Yamamoto K. Intraabdominal bleeding attributed to ruptured periumbilical varices. A case report and a review of the literatureJapanese Journal of Surgery 1987;17(1):33–36. [pmid: 3494875]|
|34.||Graham ANJ,McAleese P,Moorehead RJ. Intraperitoneal rupture of ectopic varices?a rare complication of portal hypertensionHPB Surgery 1994;7(4):315–318. [pmid: 8204551]|
|35.||Molina-Perez M,Rodriguez-Moreno F,Gonzalez-Reimers E,et al. Haemoperitoneum secondary to rupture of retroperitoneal varicealHPB Surgery 1997;10(5):329–331. [pmid: 9298389]|
|36.||Ramchandran TM,John A,Ashraf SS,Moosabba MS,Nambiar PV,Shobana Devi R. Hemoperitoneum following rupture of ectopic varix along splenorenal ligament in extrahepatic portal vein obstructionIndian Journal of Gastroenterology 2000;19(2):p. 91.|
|37.||Moreno JP,Pi?a R,Rodr?guez F,Korn O. Spontaneous hemoperitoneum caused by intraabdominal variceal rupture in a patient with liver cirrhosis. Clinical caseRevista Medica de Chile 2002;130(4):433–436. [pmid: 12090110]|
|38.||Chu EC,Chick W,Hillebrand DJ,Hu K-Q. Fatal spontaneous gallbladder variceal bleeding in a patient with alcoholic cirrhosisDigestive Diseases and Sciences 2002;47(12):2682–2685. [pmid: 12498285]|
Previous Document: A population-based clinical trial of irinotecan and Carboplatin.
Next Document: Early, low-level auditory-somatosensory multisensory interactions impact reaction time speed.